People wait to be seen by MSF’s mobile health clinic in Zelocotitlán. All photographs by Mónica González/MSF

It’s 6am and raining heavily as patients start queuing outside the health centre in the indigenous rural village where Médecins Sans Frontières (MSF) is operating a three-day mobile clinic.

It’s the team’s first time in Zelocotitlán. The village has been without a doctor for two years, leaving a young nurse to single-handedly attend to 2,000 or so people in this isolated Nahua community.

There are abundant venomous scorpions, chronic medicine shortages and no phone signal here. There is also no ambulance service as a surge in drug violence has turned this impoverished mountainous region into a virtual no-go area.

Travel to the nearest hospital is expensive and dangerous. It takes 90 minutes to get to the town of Chilapa de Álvarez, where military tanks patrol the streets but criminal gangs kill and disappear people with impunity.

The waiting area is packed with pregnant women and feverish children with chesty coughs when doors open at 8am.

Before patients are seen, the clinical team – three doctors, two psychologists and a nurse – explain that MSF is neutral, independent, free of charge and available to anyone as long as weapons are left outside.

We can’t change the reality, only alleviate some suffering

Ivana Servin

This is the standard pep talk in the state of Guerrero, where MSF has taken over 11 primary health clinics that have closed or are limited by the security crisis in communities long neglected by the state.

Guerrero, located in south-west Mexico, is a rugged mountainous state with a Pacific coastline once famed for the glitzy holiday resort frequented by Hollywood stars, Acapulco – which has now turned into the country’s murder capital. The state is ravaged by dozens of heavily armed warring gangs vying over transit routes and poppy production in the mountains.

Last year the region’s murder rate reached 69 per 100,000 inhabitants – more than three times the national average (comparatively, the UK’s murder rate is one per 100,000). The World Health Organization classifies 10 homicides per 100,000 people as characteristic of endemic violence.

In addition, there’s a heavy military presence and many communities like Zelocotitlán have created armed self-defence forces. In this zone, 700 or so elected volunteers patrol 68 communities to guard against suspicious poppy cultivation and criminal gangs. Everyone must be indoors by 10pm.

Turf wars create invisible borders, and medicines and health workers cannot or will not enter given the pitiful salaries. As a result, children go unvaccinated, risky pregnancies are undetected and patients with chronic conditions like diabetes, hypertension and epilepsy develop life-threatening complications.

In Zelocotitlán, Rafaela Garcia, 17, holds her head and cries inconsolably. Her mother explains how every couple of weeks Rafaela has terrible headaches, and visual and auditory hallucinations that last several hours until she faints. These episodes began seven years ago, but she’s never seen a specialist or taken any medication other than over-the-counter painkillers.

The teenager needs a full neurological and psychiatric evaluation, but the specialist hospital is far away in the dangerous state capital. “It’s so frustrating; with access to the right care she’d have a much better quality of life,” says Dr Lenin Martinez.

The toxic mix of poverty and violence is striking. Guerrero has one of Mexico’s lowest life expectancies at 73 years, and ranks in the bottom four of 32 states for a range of wellbeing measures including health, life satisfaction, safety and access to basic services. Almost 70% of its 3.5 million inhabitants live in poverty; one in three is indigenous.

The macabre reality of the situation in Guerrero came into focus in 2014 when 43 trainee teachers were disappeared in Iguala. The endless, unchecked brutality is destroying the social fabric of once close-knit communities and triggering widespread mental health problems such as acute anxiety and post-traumatic stress disorder.

‘Comparable to war’

In addition to regular clinics, MSF provides rapid response interventions in the aftermath of grave incidents like mass kidnappings, gun battles and massacres, which leave displaced or trapped communities in psychological turmoil.

Helmer Charris, head of the mission, and Carmelo Quiroz, a nurse, see to patients

“Emergency situations are part of our DNA as an organisation,” says programme chief Dr Helmer Charris. “The quicker we respond, the more impact we have.”

Two-fifths of the 500 patients seen by MSF psychologists in the state between January and July this year were experiencing mental health problems linked to the violence. “We listen, recognise and normalise the symptoms they are suffering, and help them take control of small things in chaotic situations,” says psychologist Ivana Servin. “We can’t change the reality, only alleviate some suffering.”

It’s mid-afternoon when Sarai Felix, 23, carries in her three-year-old asthmatic son Fredy. He’s wheezy with a nasty cough and slight fever, but responds to treatment and they go home. A few hours later after nightfall, Sarai returns as Fredy is struggling to breathe. The doctors administer several doses of medication to reduce inflammation and open up his lungs – including corticosteroids which Sarai would usually pay for at the Chilapa hospital. (The return car fare after dark is £50, 10 times what her husband earns as a farmhand.)

By morning Fredy is breathing more easily but still too weak to walk, so his mother carries him home wrapped in an embroidered shawl. They will be back for next month’s mobile clinic.

The mobile clinic moves to the neighbouring municipality of Zitlala where a health councillor was murdered days earlier. The team set up camp in a church about 15 minutes’ drive from the rural community Tlaltempanapa. The clinic closed here four years ago.

The convoy of the mobile clinic heads to Zelocotitlán village for the first time

It’s unclear how the drug war engulfed this tiny canton. MSF doesn’t pry, but the campesinos-turned-poppy farmers are said to be allied to one criminal group and at odds with powerful town caciques (chiefs). Local authorities have no idea how many unvaccinated children, pregnant women or sick people there are.

Almost 30,000 people were murdered in Mexico last year, making it the most violent on record. The newly elected president has pledged to rethink the failed war on drugs. It’s a huge challenge: homicides are up 16% in 2018 and Guerrero is one of five states issued with a “do not travel” warning by the US state department – the same classification given to war-torn Libya and Yemen.

MSF’s health clinics are not a permanent solution. The NGO’s current mandate in Guerrero ends in 2020, but around 20% of health centres in this mountainous region are currently closed or without a doctor.

“The high numbers of victims of violence are comparable to what we’d expect in a classic war, or perhaps even higher,” says Charris. “We’ll stay here, as long as we’re needed.”